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Health Ombudsman: too many lives being lost to sepsis as failures continue
The UK’s Health Ombudsman has warned that sepsis is still taking too many lives due to the same hospital failings identified over ten years ago.
Despite some progress on diagnosis and
treatment of sepsis since the publication of the report, Time to act in 2013, lessons are not being learned and repeated mistakes are putting people at risk. A new report, Spotlight on sepsis: your stories, your rights, highlights that the same serious failings are still happening, and that significant improvements are urgently needed to avoid more fatalities. Failings include delays in diagnosis and treatment, poor communication and record-keeping, and missed opportunities for follow-up care. Commenting on the report, Ombudsman Rob
Behrens, said: “I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted ten years ago are still occurring. It is clear that lessons are not being learned. “Complaints have the power to reveal the truth,
bring closure and create lasting positive change. But complaints must be handled properly, and findings acted upon. Losing a life through sepsis should not be an inevitability. “The NHS needs to listen to patients and their families when they raise concerns. It needs to be sepsis-aware. We know early detection and treatment is crucial. It is time to make sure complaints count, and patients’ voices are used to shape action on sepsis that is urgently needed.” The report shares Sue’s story. Sue’s mother, Kath,
tragically died at Blackpool Teaching Hospitals Trust after sepsis was not recognised and treated. Kath was diagnosed with pneumonia when she
was admitted to hospital in 2017. She developed other lung problems, and almost two weeks later, she fell while in hospital, had a cardiac arrest and sadly died.
More action needed to meet TB targets
The WHO 2023 Global tuberculosis (TB) report underscores a significant worldwide recovery in the scale-up of TB diagnosis and treatment services in 2022. It shows an encouraging trend starting to reverse the detrimental effects of COVID- 19 disruptions on TB services. Featuring data from 192 countries and
The investigation found Kath showed clear signs
of sepsis which caused her health to deteriorate and most likely contributed to her falling. Medical notes showed sepsis was suspected by clinical staff but was not acted upon. The Ombudsman said there was a missed opportunity to identify and treat sepsis which would have likely prevented Kath’s deterioration, and death. Kath’s daughter Sue said: “We were devastated when mum died. When the Ombudsman confirmed that her death was avoidable, it felt like we were grieving all over again. The hospital staff should have recognised the signs of sepsis and acted accordingly. If they had done, mum would probably still be with us now. I took my complaint to the Ombudsman because I don’t want another family to have to go through what we did.” The Ombudsman commented that there are
many tragic cases where patients have died, and the outcome could have been different if they, or their families, had been listened to. Martha’s Rule, if introduced, will give people the power to seek an urgent second opinion if a patient’s condition is deteriorating, or they have concerns about their care. It will play an important role in ensuring patients voices are heard. To view the full report, visit:
https://tinyurl.com/bdwc9ncn
areas, the report shows that 7.5 million people were diagnosed with TB in 2022, making it the highest figure recorded since WHO began global TB monitoring in 1995. The increase is attributed to good recovery in access to and provision of health services in many countries. India, Indonesia and the Philippines, which together accounted for over 60% of the global reductions in the number of people newly diagnosed with TB in 2020 and 2021, all recovered to beyond 2019 levels in 2022. WHO reports that global efforts to combat TB have saved over 75 million lives since the year 2000. However, even more efforts are needed as TB remained the world’s second leading infectious killer in 2022. An estimated 10.6 million people fell ill with TB in 2022, up from 10.3 million in 2021. Geographically, in 2022, most people who developed TB were in the WHO Regions of South-East Asia (46%), Africa (23%) and the Western Pacific (18%), with smaller proportions in the Eastern Mediterranean (8.1%), the Americas (3.1%) and Europe (2.2%). The total number of TB-related deaths (including those among people with HIV) was 1.3 million in 2022, down from 1.4 million in 2021. However, during the 2020-2022 period, COVID-19 disruptions resulted in nearly half a million more deaths from TB. TB continues to be the leading killer among people with HIV.
Decline in HIV but progress slow in women and ethnic minorities
A new report from the UK Health Security Agency (UKHSA) shows that there has been a continued decline in HIV transmission but progress has slowed particularly among women and ethnic minorities. The number of new HIV diagnoses among gay and bisexual men fell by 42% from 1,239 to 724 between 2019 and 2022. England also met the UNAIDS 2025 95-95-95 targets for the third time with 95% of all people with HIV being diagnosed, 98% of those diagnosed on treatment and 98% of those on treatment being virally suppressed and unable
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www.clinicalservicesjournal.com I December 2023
to pass on the virus. Despite a significant fall in cases among white gay and bisexual men between 2019 and 2022, there are groups of ethnic minority gay and bisexual men in whom new HIV diagnoses are not decreasing at the same rate. In 2022, 42% (304 of 724) of diagnoses in gay, bisexual and other men who have sex with men (GBMSM) were among ethnic minority groups compared to 34% (417 of 1,239) in 2019. Overall new HIV diagnoses first made in England fell by 13% from 2,819 in 2019 to 2,444 in 2022. However, between 2021 and 2022 diagnoses rose from 2,313 to 2,444. In order to achieve the 2025
transmission target, HIV transmission would need to fall by 627 per year. This recent rise is partly due to a slowing of progress towards elimination in heterosexual women and ethnic minority groups. Cases in heterosexual women, which despite reducing from 589 in 2019 to 447 in 2021, rose by 26% from 447 to 564 in 2022. Among white British women, diagnoses fell
by 39% between 2019 and 2022, compared to 6% among black African women. Among heterosexual men, new HIV diagnoses fell by 25% from 458 in 2019 to 281 in 2022.
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